Reducing diabetes medications in geriatric patients with low A1c involves careful consideration of the risks and benefits of continued intensive glycemic control. In older adults, particularly those with multiple comorbidities, frailty, or limited life expectancy, maintaining very low A1c levels may increase the risk of adverse outcomes, such as hypoglycemia, which can lead to falls, cognitive impairment, or hospitalizations. In this article, we will discuss deprescribing in diabetes.
The goal of diabetes management in this population shifts from strict glycemic control to prioritizing quality of life and minimizing treatment burden. For geriatric patients with consistently low A1c (e.g., below 7%), medication reduction or de-escalation may be appropriate.
Targeted Deprescribing in Diabetes – Examples
So which medications should we reduce? Sulfonylureas are at the top of my list. If there are any signs of hypoglycemia, this should be the first oral medication to be reduced and/or discontinued. Let’s say I have a patient with an A1C of 6.1 on glipizide 10 mg daily. Reducing that glipizide to 5 mg daily would be a good first step. We would also want to monitor blood sugars more closely with any adjustments. Learn more about glipizide from the Real Life Pharmacology Podcast.
For those type 2 diabetes patients who are taking insulin. gradual reductions in long-acting insulin can be an appropriate change to make in a patient’s medication regimen.
If I have a patient who is struggling with appetite and has a lower A1C, I’m going to review their medication list and ensure that we are reducing or discontinuing GLP-1 agonists. Weight loss may be a good thing in many younger patients, but weight loss in older patients who don’t need it can be problematic.
Pay attention to renal function. Metformin should be reduced or discontinued in patients who have declining renal function. I’ve talked about this in the past and metformin is one of my top 10 drugs affected by renal function. In addition to this, if I have a patient with loose stools, I’m going to target a reduction or discontinuation of metformin.
In any patient with a new onset of CHF, pioglitazone is a great target to discontinue.
In patients who have trouble with hypotension or chronic UTIs, SGLT-2 inhibitors would be a good candidate to deprescribe in our diabetes patients as these are possible adverse effects (and common knowledge for board exams!)
As you can see, not all patient situations are the same but we can improve quality of life and reduce pill burden by targeted deprescribing in diabetes.
Eric Christianson, PharmD, BCPS, BCGP
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